Health-related quality of life and associated factors among people living with HIV/AIDS in Lagos, Nigeria

Background Although people living with HIV (PLWH) now have a longer life expectancy due to antiretroviral therapy, several factors impact their health-related quality of life (HRQoL). Understanding the dimensions and determinants of HRQoL among PLWH is crucial to developing solutions to improve their overall wellbeing. Aim This research aimed to explore the HRQoL and its associated factors among PLWH in Lagos, Nigeria. Setting Seven HIV testing and treatment centres in Lagos. Methods A cross-sectional survey was conducted with 385 participants. Socio-demographic and HRQoL data were obtained using questionnaires and the Medical Outcomes Study HIV Health Survey (MOS-HIV). Logistic regression models were used to identify variables that were associated with quality of life. Results The physical health summary and mental health summary scores measured by the MOS-HIV were 54.2 ± 5.3 and 56.3 ± 6.7, respectively. Being married, having higher levels of education, shorter duration of HIV and higher income levels were significantly associated with better HRQoL. The duration of HIV was found to have an inversely proportional influence on the quality of life of PLWH, both in physical health (χ2 = 9.477, p = 0.009) and mental health (χ2 = 11.88, p = 0.004) dimensions. Conclusion The HRQoL of PLWH in Lagos, Nigeria was relatively low. Education, duration of HIV, marital status and income level are predictors of HRQoL. Contribution This study is valuable for healthcare professionals and policymakers, providing them with essential information to tailor interventions and allocate resources effectively to improve the overall wellbeing of PLWH in Nigeria.


Introduction
Of the estimated 37.9 million persons with HIV (PLWH) living in the world, 67.5% are in Africa. 1 Despite the low prevalence of 2.1% (1.9 million PLWH), Nigeria has the second-largest population of PLWH in the world. 2 Although there has been an increase in access to Anti-Retroviral Therapy (ART) in Nigeria, the rate of new infections and opportunistic infections, such as tuberculosis, has risen in the past year. 1This indicates that although mortality rates among PLWH may fall, they are, however, prone to a diverse range of health-related challenges because of the HIV infection and their use of ART.
The Federal Government of Nigeria led by National Agency for the Control of AIDS (NACA) in the recent National HIV/AIDS strategic framework 2021-2025, 3 emphasised the aim for Nigeria to be AIDS-free by 2030, with no new infections, discrimination, or deaths because of the disease.One of the seven principles guiding this strategic framework is 'to ensure care and support for all people living with and affected by HIV'. 4 Central to this target is the UNAIDS 95-95-95 goal of ensuring that, 95% of persons living with HIV are aware of their HIV status, 95% of patients diagnosed with HIV undergo ongoing antiretroviral medication and 95% of people on antiretroviral medication maintain viral suppression. 5Currently, these strategies have aided in transforming HIV/AIDS from a deathly acute infection to a chronic disease, as PLWH are living longer lives because of improved access to ART. 6 Thus, these strategies collectively aim at improving the health-related quality of life (HRQoL) of PLWH.
Background: Although people living with HIV (PLWH) now have a longer life expectancy due to antiretroviral therapy, several factors impact their health-related quality of life (HRQoL).Understanding the dimensions and determinants of HRQoL among PLWH is crucial to developing solutions to improve their overall wellbeing.
The definition of HRQoL continues to be debatable.According to the World Health Organization, quality of life is defined as 'the individual's perception of their position in the context of culture and value systems in which they live and in relation to their goals, expectations, standards and concerns'. 7This concept renders quality of life (QoL) subjective and specific to a person, his or her culture, and environment.Although an individual's personal view about their quality of life may alternate throughout their life, 8 the multidimensional concept of HRQoL encompasses various domains such as emotional health, physical health, social functioning (SF), and pain, which play a vital role in how an individual rates their overall perception of general health. 9,10n furtherance of this, various factors that could impact the HRQoL of a PLWH have been explored, 11 and findings reveal that sociodemographic characteristics, presence of comorbidities, socioeconomic status, environmental factors, coping mechanisms, and clinical factors could influence the HRQoL of PLWH.
Studies exploring the influence of various factors in determining the QoL of PLWH have been assessed nationally 12,13 and globally. 14,15,16Findings from these studies reveal that the determinant factors vary and range across physical, psychological, social and financial domains. 17,18These factors also differ across participants based on geographical locations, ethnicity, gender, and other concurrent factors. 11veral instruments have been utilised in measuring the HRQoL of PLWH. 19Considering the diverse instruments employed to assess the HRQoL of PLWH, including widely used measures such as the Medical Outcomes Study HIV Health Survey (MOS-HIV) and the World Health Organization Quality of Life (WHOQOL)-BREF, 20 the literature on HRQoL among PLWH in Nigeria lacks consensus.While Ogbuji and Oke 21 utilised the 'HIV Symptom Scale' (HSS) and the 'Quality of Life Scale' (QOLS) to report poor quality of life in Ibadan, Nigeria, a study in South-East Nigeria using the WHOQOL brief version tool indicated an overall good HRQoL among adolescents and adults. 22Similarly, Salako et al. 23 2022 assessed HRQoL in Lagos, focusing on children and adolescents with the Paediatric Quality of Life Inventory [PedQoL™] and reported favourable HRQoL scores.This divergence in findings underscores the need for a comprehensive understanding of the factors influencing HRQoL in the Nigerian context.
A scoping analysis of HIV/AIDS in Nigeria 24 from 1986 to 2021 surmised that although there is an increase in scientific literature pertaining to HIV/AIDS-related research in Nigeria, there are still unexplored grey areas, such as the relationship between sociodemographic status and quality of life among PLWH in 'key population hotspots' 25 which had not been precisely characterised.Understanding the factors impacting the HRQoL among PLWH is crucial for identifying potential confounding variables and understanding how different demographic factors may influence the HRQoL of PLWH.Additionally, sociodemographic data can provide insights into the distribution of health outcomes among PLWH which may assist policymakers to allocate resources effectively and implement policies that address the distinct needs and challenges encountered by PLWH. 26Hence, the primary objective of this research is to assess the current status of HRQoL and identify the factors associated with it among PLWH in Lagos, Nigeria, using the MOS-HIV questionnaire.

Study design and participants
This cross-sectional study was conducted between July 2022 and January 2023 in Lagos, Nigeria.With Lagos being one of the key population hotspots for targeted HIV programme planning in Nigeria, 25 seven HIV/AIDS testing and treatment centres in Lagos were randomly selected as study sites for the survey.The required sample size was determined using relevant literature 22,27 and the Cochran's sample size equation for categorical data 28 : where: t = value for selected alpha level of 0.025 in each tail = 1.96; d = acceptable margin of error = 5%; and (p)(q) is the estimate of variance = 0.25.
Thus, a minimum sample size of 385 participants was calculated.Participants were selected using convenience sampling, and the following inclusion criteria were applied in determining the eligibility of participants: • people living with HIV; • people above the age of 18; • people who voluntarily indicated interest to participate and are able to consent.

Data collection
Data collection was done using paper questionnaires.The principal investigator was assisted by two physiotherapists who worked as research assistants for the study.All researchers underwent training on administering the questionnaires and provided information to participants about the study's purpose, content and potential risks before data collection.Participants completed the anonymous questionnaires independently while the researchers provided detailed clarification and recorded answers for participants who had difficulty understanding or reading the questionnaire.

Measurements Sociodemographic characteristics
The sociodemographic survey tool used in this study provided information on the age, gender, educational qualifications, income range, duration since HIV diagnosis, and ART information of participants.

Medical symptoms
Based on literature and clinical experience, common symptoms experienced by PLWH were included in the questionnaire.This questionnaire asked participants to respond 'yes' or 'no' to symptoms they had experienced over the previous 14 days.

Health-related quality of life
The MOS-HIV was utilised as the primary measure of HRQoL.Medical Outcomes Study HIV Health Survey is a widely used 35-item questionnaire that comprehensively assesses various dimensions of health relevant to HIV/AIDS, 29 including general health perceptions (GHP), pain, physical functioning (PF), role functioning, SF, mental health (MH), energy, fatigue, cognitive function, and overall quality of life.Previous studies have reported satisfactory reliability, with a Cronbach's α coefficient exceeding 0.7 for group comparisons, 30 indicating adequate internal consistency.Additionally, validity has been established for the physical health summary (PHS) and mental health summary (MHS) scores of the MOS-HIV. 30Scoring of the questionnaire involved a two-step process: firstly, numerical values were re-coded, and then each item was scored on a scale of 0 to 100, with higher scores reflecting better functioning and overall well-being.Secondly, to estimate the 10 domains of patient functioning, items from the same scale were averaged.

Statistical analyses
The data from the completed questionnaires were captured in Microsoft Excel and imported into IBM SPSS 25 ® for analysis.Descriptive statistics were utilised to summarise all demographic variables.For the quantitative measures, continuous variables were presented as mean ± standard deviation (M ± s.d.) while categorical variables were described using percentages.Using the MOS-HIV scoring protocol, 30 1.

Factors associated with health-related quality of life
Table 4 shows that in the univariate analysis, higher education level was significantly associated with overall PHS, while being married (χ 2 = 1.326, p = 0.022) and having higher income levels (χ 2 = 14.628, p = 0.002) was linked to better MHS.Shorter duration of HIV was associated with better PHS (χ 2 = 9.477, p = 0.009) and MHS (χ 2 = 11.88,p = 0.004).

Factors associated with health-related quality of life in the multivariable logistic regression
The results in Table 5 show that only duration of HIV diagnosis was significant in PHS and MHS in the univariate analysis and multivariate logistic regression analyses.People living with HIV who had a secondary school education showed significantly increased odds ratio (OR = 3.83; CI; 1.45-10105, p = 0.007) suggesting that secondary school education is associated with higher odds of better PHS HRQoL.
Similarly, compared to the reference category of widowed or separated individuals, the results show that marital status plays a significant role, with married (95% CI: 0.13, 0.80, p = 0.014) and single (95% CI: 0.11, 0.74, p = 0.010) individuals exhibiting a substantially lower odds ratio of 0.32 and 0.28 respectively.Thus, this suggests that being married or single is associated with a reduced likelihood of experiencing poor MHS compared to being widowed or separated.Income levels also show a significant association with MHS.Individuals with an income between ₦18 000 and ₦30 000 display a notably lower odds ratio of 0.29 (95% CI: 0.11, 0.75, p = 0.011), indicating a decreased likelihood of poor MHS compared to those with an income less than ₦18 000.
The Hosmer-Lemeshow goodness-of-fit test yielded p-values of 0.989 and 0.082 for the PHS and MHS models, respectively, indicating well-fitting models.These models accounted for approximately 7% of the variability in PHS (Nagelkerke R 2 = 0.077) and 10% of the variability in MHS (Nagelkerke R 2 = 0.105).

Discussion
Findings from this study revealed that the total PHS and MHS of HIV/AIDS in Lagos, Nigeria were 54.2 ± 5.3 and 56.3 ± 6.7 respectively, which were higher than those in previous studies surveyed in other sub-Saharan countries. 14,31lthough the MOS-HIV is a widely used, reliable and validated instrument for HRQoL evaluation in PLWH, 29,32 no parallel comparison could be drawn between our study and those conducted in other parts of Nigeria, as previous studies were conducted using other HRQoL instruments such as the World Health Organization Quality-of-Life-HIV Bref -WHOQOL-HIV BREF, 33 Short Form-36 -SF-36, 34 European Quality-of-Life Instrument-5 Dimension -EQ-5D. 12However, findings from these studies all reported good HRQoL among the participants, who were living with HIV in Nigeria.
Irrespective of the measurement tool, HIV-specific HRQoL outcomes vary by country and region, with some studies showing higher overall scores than our findings. 35These distinctions may be ascribed to variances in healthcare infrastructure, access to treatment and cultural variables impacting perceptions of health and well-being.
Although the lowest score was reported in the health perception domain (49.3), participants in our study scored highest in MH (60.0) and HD (70.0) domains, which is similar to other studies. 36,37,38While several factors could be responsible for these varying results, this underscores the complex interplay between physical and MH aspects in the quality of life of individuals with HIV.One notable finding is the positive correlation (Spearman's rho = 0.243, p < 0.01) between mental and PHS scores.This indicates that individuals with higher MH scores also tend to report better physical health and vice versa.This correlation emphasises   39 Several factors may contribute to health-related stress among this population.
In the present study, participants reported that they experienced headaches, weight loss and muscular pain in the previous 14 days (36.6%, 27.8%, and 16.9% respectively).These are common findings in studies conducted among the HIV population. 40Because of the HIV infection and adverse effects of the ART, symptoms cluster commonly reported among PLWH include depression, anxiety, insomnia, fatigue,  nausea, vomiting, joint pain, and headache, all of which negatively impact the QoL among PLWH. 40Similarly, energy and fatigue scores (50.5 ± 4.9) indicate a substantial burden of fatigue experienced by PLWH in this population, which might impact their daily activities and overall functioning.Thus, studies that focus on fatigue management and selfperception of health promotion are needed.
The findings of this study show that education level was significantly associated with PHS.With majority (70%) of the participants educated only up to the secondary school level, the impact of education level on PLWH cannot be overemphasised.As evident from findings of previous studies, 38,41 education level is a significant predictor of HRQoL among PLWH.Furthermore, having little formal education is a barrier to getting health treatments, leading to an escalation of unsafe sexual practices, 42 and subsequently increasing the vulnerability of PLWH.Therefore, health interventions for PLWH should take into consideration the impact of education level and ensure that PLWH have a clear understanding of their health conditions and management strategies during hospitalisation and follow-up visits.
Duration of HIV infection was an independent risk factor that was significantly associated with the PHS and MHS of PLWH.This implies that irrespective of other confounding factors, the likelihood of experiencing physical and MH challenges or complications increases as one ages with HIV.The long-term implication of this is that policy makers and health professionals' interventions must evolve to address both the intrinsic capacity of PLWH and the external environment. 43other noteworthy sociodemographic factor in this study was that MHS was significantly associated with marital status and income level of the participants.The finding that married individuals exhibited better HRQoL compared to widowed, separated or single individuals may be attributed to several factors.Marriage often provides emotional support, companionship and a sense of belonging, which can positively impact mental well-being and overall HRQoL. 44,45arried individuals may also benefit from shared responsibilities, financial stability and social engagement, all of which contribute to a higher perceived quality of life.Additionally, marriage may offer a protective effect against loneliness and social isolation. 45Married individuals have access to greater social support networks and resources, which can buffer against the negative effects of living with HIV and associated challenges.
Furthermore, our study findings suggest that individuals with an income between ₦18 000 and ₦30 000 have a significantly lower likelihood of experiencing poor MHS compared to those with an income less than ₦18 000.The odds ratio of 0.29 indicates that individuals in the higher income bracket have a substantially reduced risk of poor MHS.With over half (59.3%) of the participants in our study earning less than ₦30 000 ($65.07) monthly, which is the minimum wage in Nigeria, 44 the socioeconomic impact of HIV cannot be overlooked.
Understanding the socioeconomic factors associated with HIV allows policymakers to develop more effective and inclusive policies aimed at mitigating disparities and improving outcomes for affected populations.Moreover, by acknowledging the socioeconomic determinants of health, healthcare providers can offer holistic care that addresses not only the medical aspects of HIV but also the social and economic factors that influence health outcomes. 45This may involve connecting patients with social support services, financial assistance programmes, and vocational training opportunities to enhance their overall well-being and quality of life.By addressing the underlying social and economic factors that contribute to HIV-related disparities, healthcare professionals and policymakers can work towards achieving better health outcomes and promoting equity in healthcare access and delivery.Thus, further research is needed to understand potential interventions to improve quality of life and address confounding socioeconomic disparities among affected populations.

Study limitations
Nearly one-third of the participants reported experiencing weight loss during the 14-day period.However, as the study did not include objective measurements of weight before and after this timeframe, it is challenging to accurately quantify the extent of weight loss.This lack of objective data underscores a broader limitation inherent in self-report crosssectional studies, where reliance on participants' subjective accounts may introduce inaccuracies or biases.Another limitation was that the study was conducted only in Lagos state.Future studies need to be conducted in other HIV/ AIDS 'key population hotspots' in Nigeria to determine the variation in quality-of-life scores across geographic areas.Also, the cross-sectional design of our study prevented us from establishing the precise causality between HRQoL and its associated factors.Consequently, further research aimed at exploring causal relationships between these variables is vital.

Conclusion
Our study revealed that the HRQoL of PLWH in Nigeria is relatively low.The findings highlight the importance of addressing the multifaceted determinants of HRQoL among PLWH in Nigeria.By understanding these determinants, healthcare professionals, policymakers and stakeholders can work together to improve the quality of life for PLWH, thereby enhancing their health outcomes and promoting a more inclusive and supportive environment for individuals living with HIV.

Table 2
outlines the medical symptoms of the participants.All participants were on ART.The range of duration since diagnosis spanned from 6 months to 21 years with a median of 4, and 80% of the participants were diagnosed in the second decade of the 2000s (2011-2020).Headaches were the most commonly reported medical symptom (36.6%).

TABLE 1 :
Sociodemographic characteristics of the people living with HIV in Lagos, Nigeria (N = 385).
Note: For some participants, income and education level data were not provided in the questionnaire.Therefore, the total number of participants for these variables is less than the total sample size of 385.Mean ± s.d.= 42.22 ± 10.43 (Ages: 18-30 years).s.d., standard deviation.http://www.phcfm.orgOpen Access

Table 3
shows that the mean (s.d.) for the PHS score is 54.2 ± 5.3 and MHS score is 56.3 ± 6.7.Of the 10 domains, the highest mean was found in the pain domain 57.2 ± 6.3 and the lowest mean was found in GHP domain 49.1 ± 5.1.

TABLE 3 :
HIV-related quality of life in patients with HIV -Summary scores and dimension scores.

TABLE 2 :
HIV information and medical symptoms in the last 14 days (N = 385).

TABLE 5 :
Factors associated with health-related quality of life in the multivariable logistic regression (N = 385).
PHSS, Physical health summary score; MHSS, Mental health summary score; OR, odds ratio; CI, confidence interval; P, p-value (level of significance).

TABLE 4 :
Association between sociodemographic characteristics and physical health summary score mental health summary score.